9812-236 (SFD)`LICENSED CONTRACTOR DECLARATION .
I hereby affirm•under penalty of perjury that I'am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class / Exp. Date
1411 -16`6 i3 ,�S<li�� <:r'stiivu
tate Signature of Contractor' A,/—Z • •,:.�.--.....
OWNER -BUILDER DECLARATION`
I hereby affirm under penalty of perjury that I am exempt from,the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the; project ,(Sec. 7044, Business &' Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION,
I hereby affirm under penalty of perjury one of. the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor'Code, for,the
performance of the work for which this permit is issued.
(. )' I' have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
s^.,Lil+1C;•'T�'+1�it:,(trtl�iwL�i"S a�'CCS�s::•vG.�ir i
(This section need not be completed if the permit' valuation is for $100.00 or less):
O I certify that in the performance of the work for which .this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of SAtion"L 40.37o�'f �.e'Labor
wr....
Cpde, I s all forte, comply with tfi6se provision5.�
spate: l bl4;4 Applicant
Warning: Failure to secure Wo(kers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100;000, in
addition to the cost of compensation, damages as provided for in Section 3706 .�
of the Labor Code, interest and attorney's fees.:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the .conditions and restrictions set . forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for, 180 days.will subject permit to cancellation.
I certify that !,have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned. property for I ggpe. tion pups
Signature (Owner/Agent) t A Date
PERMIT #
BUILDING PERMIT�_��
T�5;I3'i7.{9th
DATE VALUATION�.8 LOT 5'1* TRACT 2`35-2JOB
SIfE
ADDRESS '!'.!^•4158ViNT � V110"APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�Mr11 'rrAIArNv
aKFSLt
KSL, il..(.k�r'11CaA%. i ATj3ti
ryYAahtlD
7:
346 Kiik 4VD
LA Q7 AK W CA, 927.53
LA. QUIN FA CA 92253
)564-11160 030 123
USE OF PERMIT
D-WIRUA G,
}
S.ra- A -10T f# 57, K. AN 44 -MT. V004T DOV S NC)T INCLUDE :B..LOCK
WALL OR POOL. T..I N Gi k.Eta 1�1��1�E1C I y >v'_� o:P A7 -t lVl :ti.lP`L.1 .
383U:AiVC E 01 PLAN TYPE,
CUSTOM CONa`rRUC TION .11680.00 SP
rf.SMAg9teED COST
yra;liVI.t1Jr'•"11013 rte• 101-000-418-01V 5748.00
KA"N C! -W_ K RE i g
117C'.FIANICAL Ms 10:1 -00024"•.'i -OW �137,�ic1
El 8,an k10A1.:1.15C- I01r000 4202 000 1.630
PLUMBI'ma ME 101.OCH?-419`000 S169.75
mt:oNcy moro? q m P Fs f D 1- o l -0M-241-0th!
C,: ? 31G .t?%ES X01.000 � fJ00 Vxoo
I VRASTWOTUAS FE a25-000-4-13-342 $2,944.62
A10: SN PUHLIC PLACES - R SLL' 701--OW-245=000
90,340T ], C=0PI�,rUC_n_0N ANS PLAY, (,'-MFC
�1�„3�i�.,C�►
LESS PRE P�tH, ���S
$0.00
'TOT J! L PFIkiNIF V�.CS DIAD, NOW
54,386.139
RECEIPT
DATE°tta,
BY
DATE FINALED
INSPECTOR
t 17
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
fj(
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
Framing
_
F.A.U.
Compressor
Insulation
0
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
G
Final
�fI Ark—
Final — <.`/
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS-
Gas Test
Electric Final
Waste Lines
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
,Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main'Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) C10
COMMENTS: